1750655353 NPI number — MR. OGBANEDI JOHN ABU PHYSICIAN ASSISTANT

Table of content: MR. OGBANEDI JOHN ABU PHYSICIAN ASSISTANT (NPI 1750655353)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1750655353 NPI number — MR. OGBANEDI JOHN ABU PHYSICIAN ASSISTANT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ABU
Provider First Name:
OGBANEDI
Provider Middle Name:
JOHN
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
PHYSICIAN ASSISTANT
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1750655353
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/28/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 580244
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ELK GROVE
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
95758-0005
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
209-472-6624
Provider Business Mailing Address Fax Number:
209-477-1065

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
415 W BENJAMIN HOLT DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
STOCKTON
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95207-3958
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
209-477-4103
Provider Business Practice Location Address Fax Number:
209-477-1065
Provider Enumeration Date:
02/28/2012

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363A00000X , with the licence number:  PA22087 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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